rcpath - bac

Cytopathology Study Day

16 April 2017

Guy’s Hospital London

RCPath - BAC

Digital cytology: EUS FNA

pancreas and head and neck

R. Dina MD, FIAC, FRCPath

Consultant Cyto/Histopathologist

Hon Sen Lecturer

Hammersmith Hospital

Imperial College NHS Trust

Advantages of whole slide imaging in cytopathology practice. From :Patholog Res Int. 2011; 2011: 264683. Walid E. Khalbuss, 1, 2 * Liron Pantanowitz, 1, 2 and Anil V. Parwani 1

(1) Primary diagnosis (telecytology)

(2) Remote second opinion consultation

(3) Educational activity within the institution or remotely

(4) Archiving interesting and legal cases (digital cytology slides replication)

(5) Quality assurance

(6) Educational conferences such as tumor boards (locally or remotely)

(7) Online cytology proficiency testing

(8) Online board exam or certification

(9) Detailed image analysis and cytomorphometry

(10) Annotation of various entities on the slides for teaching purpose

(11) Easy acquisition of static images from whole-slide images

(12) Provide cytopathology services to remote hospitals

(13) Gains access to cytology subspecialty expertise

(14) Remote on-site evaluation and triage

(15) Synchronous consultation

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140195/

Disadvantages of whole slide imaging in cytopathology practice

(1) Costly: an expensive initial setup and storages

(2) Limited focusing functions at present

(3) Scanning time

(4) Storage: large file size

(5) Training requirements

(6) Limited validation studies

(7) Lack of standardization: multiple vendors, software, and lack of interoperability

(8) Information technology infrastructure support (bandwidth limitation of networks)

(9) Professional reluctance to adopt

Patholog Res Int. 2011; 2011: 264683.

Walid E. Khalbuss, 1, 2 * Liron Pantanowitz, 1, 2 and Anil V. Parwani 1

1Division of Pathology Informatics, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh,

PA 15232, USA2Division of Cytology, UPMC Shadyside Hospital, 5150 Centre Avenue, POB2, Suite 201, Pittsburgh, PA 15232, USA

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140195/

Use of Digital Imaging At Imperial College we have been using in the past fixed digital

images for

cytology tests during our MSc in Cytopathology

Cytology mock exams during our Advanced Courses which prepare for the MRCPath examination

WSI for research purposes and testing.

We currently informally review WSI of cases but we do not issue a formal report on them. This is because although technology on the different platforms available on the market has markedly improved we do not feel that there is an agreed standardised practice for it.

Conclusions WSI is here to stay and is fast improving and getting

cheaper

It is an important teaching and training tool

It is used for EQA schemes and Quality Assurance

It is used in MDT meetings (Tumour Boards)

It helps retaining a screening component to all

assessment tests

BUT…… it is one of the many tools!

Digital Histology vs digital

Cytology

Digital Histology and digital Cytology need a different

technical approach for many reasons


Cytology Dimension:


Cytology The nature of the material is different:

Histology

Cytology


Cytology The microscopy is different:

A histological slide requires minimal focus adjustment

Micro focusing is the “essence” of cytological screening


Cytology The scanning technique is different:

If the scanner autofocus works well, a single layer virtual

slide allows a high quality screen of a histological

preparation.

A multi level scanning is compulsory to get an acceptable

cytological virtual slide.


Cytology


Cytology In essence:

Digital Histology is two dimensional

Digital Cytology is three-dimensional.

This entails at least four problems.

Digital Cytology: a 3D

problem The first:

How many levels are needed to define "acceptable" a

virtual slide?

An immediate and seemingly logical answer is:

The more the better


problem The second problem:

Which is the optimal distance between each level?


problem

Strictly related to the first two

parameters comes the third problem:

the size of the file.


problemThe relationship between file dimension and number of levels is linear.

Just for example:

In four years in the Ljnkoeping University Hospital Pathology department (Sweden) about 1 000 000 histological slides have been scanned . The space occupied is 400TB.

The same number of cytological cases scanned with just 5 levels would need

400 x 5 TB = 2000TB

Actually a huge amount of space!


problemFinally the fourth problem: the time needed for a multi level

scanning.

A 20x20 mm wide area can be scanned in about 50

seconds.

The same area scanned with 5 z-stack levels takes more

than 4 minutes


problemThis technique consists 3 steps:

1. dividing in small areas (tiles) the image resulting from the scanning of each level

1. taking the best-focused tile from each layer

1. building a new virtual slide where all the objects result in focus

Leve

l 1

Leve

l 2

Leve

l 3

New single level

image


problemThe final result is a single level virtual slides where all the

tiles are perfectly in focus.

Pros: - small dimension of the file

- good “visual” results

Cons: - long processing time

- a lot of unnecessary data generated


problem


problemA second interesting method is proposed in


problem

A specific software generates during the scanning a three

dimensional focus map of the cells in the slide.

Following this map the scanner takes only the images of the cells

avoiding the generation of unnecessary and unwanted data.

1) The research has used the Google search engine:

www.google.com;

2) Searched nouns as keyword: nouns had to be the

most concise as possible. The used keywords are:

cytology web sites, cytology atlas, cytology and

cytopathology journal, and cytology societies;

How many web sites use

digital cytology?

http://www.google.com

1) Sponsor, scientific society, personal web page, academic institution or commercial site: whether a website is sponsored by a Society, a particular product or interest group, the owner of the web site. Personal web page web sites can list the author of the information and biographical information.

2) Society: the name of the involved Society.

3) Purpose: to provide educational information, professional advice, promoting the profession of cytologists, encouraging the science of cytology. Many web sites provide information on topics of interest to the owner, as well as tutorials or opinions.

4) Topic: FNA, gynaecologic or non-gynaecology cytology.

5) Target groups: whether the web site is recommended to cytologists, cytotechnologists, cytology trainees or students, laboratory personnel.

Criteria

6) Access: public, only registered members, any payment fees required.

7) Educational resources: each web site has been checked whether with or without educational purpose or to improve academic success.

8) Imaging: static or dynamic as virtual slides.

9) Passive or interactive: some web sites have just slides to look but no possibility to have an interactive approach. Other web sites allow the visitors to take quizzes or view solutions previously hidden, in order to test trainees or students.

Criteria

The number of web sites is about 671,000 results for

each keyword. Sites with only histopathology have

been excluded.

Based on the above mentioned criteria, the number of

web sites considered adequate is 31.

Results

There are numerous web sites available

Aims are different

Few are available in multiple languages

Cytology is notoriously more difficult to

comprehensively scan

Too few web sites are completely free to use

Few offer interactive e-training

However it is getting better all the time!

Conclusions

Incidence of Pancreatic Tumours Ductal adenocarcinoma - 80%

include all the variants, then 90%

Other tumours - 10%

MCN - 2%

PET - 2%

IPMN - 1%

Acinar carcinoma - 1%

Serous cystadenoma - 1%

SPPT - 1%

Pancreatoblastoma

Ductal Adenocarcinoma of the

Pancreas

85% of all pancreatic malignancies

Increasing incidence 4-5000pa in UK

M1.6:1F

55-75 years (average 60)

2% < 40 years

Incidence of Pancreatic Cancer

Ductal Adenocarcinoma of the

Pancreas- Investigations

CA19.9 >70IU/mL

Biopsy -

Core needle (histology)

FNA

Biliary brushings

Why cytology?

Resectable - just take it out?

Medical-legal issues related to a bad outcome with benign

disease

10% of jaundiced patients with an “obvious” malignant mass prove

to have a benign lesion

Potential for lymphoma diagnosis, a non-surgical disease

Cystic lesions

Patient compliance

Why cytology?

Unresectable, just leave it in?

Not all large masses that appear unresectable are ductal

adenocarcinoma

advances in surgical and anaesthetic practices have

improved surgical outcomes even in older, less fit patients

a positive tissue diagnosis is mandatory before

chemotherapy or radiation therapy can be instituted

Pancreatic Mass: Solid or

Cystic? Solid Pancreatic masses

- ductal adenocarcinoma

typical

variant

- chronic pancreatitis

- Acinar cell carcinoma

- pancreatic endocrine tumour

- pancreatoblastoma

Cystic pancreatic masses

- pseudocyst

- serous cystadenoma

- solid pseudopapillary tumour

- mucinous cyst

MCN

IPMN

EndosonographyHigh frequency miniature

ultrasound transducer is

incorporated into the tip of a

conventional endoscope

resulting in enhanced

resolution of the GI wall and

structures with close

proximity to the GI wall

USS advantages

High intrinsic spatial resolution

No ionizing radiation

Inexpensive and easily portable

USS Disadvantages

Gas and bone impede the passage of USS waves

As good as the operator

Types of Echoendoscopes

Radial

Linear

Miniprobes

Advantages of EUS and EUS

Guided FNAB Biopsy

Not percutaneous FNAB

no reported cases of needle tract seeding with EUS FNAB

Small trajectory to target compared to percutaneous method

More sensitive than CT for small masses (0.5 cm vs 2cm)

cost effective relative to CT biopsy

Staging/determining resectability

distant metastases or SMA invasion=unresectable

peripancreatic nodes and accessible liver lesions can be biopsied during the same procedure

Disadvantages to EUS and EUS

Guided FNAB

Expensive equipment

Technically difficult and requires significant

expertise

low tissue yield with inexperience

Currently no good core biopsy method

GI contamination of cytology specimens

particularly a problem with cystic lesions

EUS-guided FNA for diagnosis

of solid pancreatic neoplasms

False –ve results up to 20-40 %

False positive very rare

Optimizing diagnostic yield from

EUS-FNA. Cytopathology June 2013

ROSE increases diagnostic sensitivity and accuracy of

FNA for solid pancreatic masses by up to 10-15 %

Meta-analysis of 34 studies with 3644 patients : ROSE :

p=0.001 for accuracy

High Grade Adenocarcinoma Marked nuclear

atypia

hyperchromasia

pleomorphism

overlapping

Prominent nucleoli

Single atypical cells

Mitoses

Coagulative Necrosis

High Grade Adenocarcinoma

win.eurocytology.eu/virtualslides/git-eus/vs-064

Pitfalls

Liver cells

Intestinal cells

Mesothelial cells

Endothelial cells

Early stages of Chronic active

pancreatitis

Both ductal and acinar cells

Background inflammation

Granulation tissue

Fat necrosis

Late Chronic Pancreatitis

• mostly ductal cells

• few to no acinar cells

• some islet cells

• monolayered sheets

• cohesive, few single cells

• maintained polarity

• minimal nuclear overlap

• mild anisonucleosis

• smooth nuclear membranes

• rare/normal mitoses

• no coagulative necrosis

Acinic cell Carcinoma Rare primary tumour

Highly aggressive but better 5 year survival than ductal carcinoma (50% vs. <10%)

Mostly adult men but can be seen in children

Presentation variable but generally non-jaundiced (in contrast to ductal ca.)

Small %- syndrome of disseminated fat necrosis/ polyarthralgia due to serum lipase secretion by tumour

Acinic cell carcinoma

High cellularity

No ducts

No fatty stroma

Poorly formed acini

Variable cells

Atypia variable

Pancreatic Endocrine Tumours

• PET can be cystic due to central necrosis

• PET, cystic or solid, located most commonly the body and tail

• Most cystic PET are non-functioning

Neuroendocrine Cytology

Pancreatic Endocrine Tumours

• homogenous small cell population

• loosely cohesive clusters and single cells

• plasmacytoid morphology not uncommon

• round to oval nuclei

• coarse, speckled chromatin

• nucleoli also not uncommon

• chromogranin should be positive

(Pancreatic?) Endocrine

Tumours

Chromogranin Calcitonin

Pancreatic cysts(most common and clinically relevant)

Pseudocyst

Serous cystadenoma

Solid pseudopapillary tumour

Mucinous cysts

mucinous cystic neoplasm

intraductal papillary mucinous neoplasm

Pancreatic Pseudocyst

Most common cystic lesion in the pancreas (75-90%)

Associated with pancreatitis, trauma, surgery

Thick walled, unilocular, +/- communication with duct

Fluid aspirated is often dark and not viscous

Pancreatic Pseudocystcytology

Cyst debris with blood, proteinacous material and sometimes bile

variable inflammation

NO cyst lining epithelium (beware of contamination, mucin and

epithelium)

Serous Cystadenoma

• benign neoplasm in the head and tail of elderly

men and women

• star-burst calcifications within a central scar

diagnostic on imaging when present, but this is

rarely present

• most tumours are “microcystic” with multiple,

<2cm cysts, but can be unilocular due to specific

variant or due to haemorrhagic degeneration,

causing problems with imaging diagnosis

Serous Cystadenoma

Watery, non-mucinous fluid

scant cellularity

clean, proteinaceous or bloody

background

monolayered sheets or small,

flat clusters

bland, uniform, round nuclei

scant but visible non-mucinous

cytoplasm

Mucinous Cysts of the PancreasWHO Classification

Mucinous cystic neoplasm

Mucinous cystadenoma

Borderline mucinous cystic neoplasm

Mucinous cystadenocarcinoma

Intraductal papillary mucinous neoplasm

Intraductal papillary mucinous adenoma

Intraductal papillary mucinous neoplasm of borderline malignancy

Intraductal papillary mucinous carcinoma

Intraductal papillary mucinous neoplasm with invasive carcinoma: tubular type or colloid carcinoma

Mucinous Cystic Neoplasms (MCN)

Lined by mucinous,

generally non-papillary

epithelium, but can be

focally papillary

Associated with a

subepithelial “ovarian-like

stroma” (females)

Predominantly in middle

aged females

Mostly in the pancreatic

tail

Cysts do not

communicate with the

pancreatic ductal system

Thin septae

Mucinous Cystic Neoplasms (MCN)

Intraductal papillary mucinous

tumour (IPMT)

Main duct or branch duct types

Macroscopic papillae or mucin

Focal or diffuse > 1cm

PanIN < 5mm

M>F (Main Duct Equal)

60 years average

Thank you!

rcpath - bac

Documents